Soon after taking office in October 2019, Health Minister Terawan Agus Putranto highlighted the urgency for community health centers (Puskesmas) to focus on preventing diseases and promoting health to help reduce the burden on the country’s deficit-stricken national health insurance (JKN) program.

Only a few months later, Puskesmas across the country are doing both while conducting public health monitoring and providing treatment for a different reason: the COVID-19 outbreak.

Puskesmas staff are now expected to educate people on the disease, trace contacts, monitor suspected cases and administer rapid tests, all while treating COVID-19 patients without sufficient personal protective equipment (PPE), risking greater exposure to the invisible threat.

“At first, we had to use thick [rain jackets and pants]. We had to maintain our distance, avoiding physical contact with our patients,” said general practitioner Christine Yulius, 40, the sole resident doctor at a Puskesmas in Tasikmalaya, West Java.

It was only recently that PPE was distributed to health centers, though the supply did not include medical gowns or hazmat suits.

PPE shortages have been reported at Puskesmas across the country, according to Health Ministry Healthcare Services Director General Bambang Wibowo.

Bambang said last week at a teleconference that amid the apparent “limited availability” of protective gear, community health centers were expected to use the equipment “efficiently [...] to save [on PPE] while being protected from the risks of COVID-19 exposure” in their prominent role in Indonesia’s fight against the epidemic.

“Puskesmas have a very big and necessary role, [...] from prevention and screening to response,” he said.

With a population of some 267 million people across the vast archipelago, Puskesmas had been the backbone of the national healthcare system even before the outbreak, dealing with the triple burden of diseases: communicable diseases like HIV/AIDS, noncommunicable diseases such as diabetes and heart disease and reemerging infectious diseases like malaria.

According to the Health Ministry’s 2018 data, the country has 2,813 hospitals, some of which are currently overwhelmed by a surge in patients, and 9,993 Puskesmas, many in remote coastal villages and inland regions.

Community health centers typically have several general practitioners on staff, at least one dentist, a few nurses and a midwife, and have fewer facilities and equipment than hospitals. The data shows that 3,623 Puskesmas also provide inpatient care.

Despite the long waiting time at most Puskesmas, people flock to them to seek free treatment for 144 types of diseases and obtain hospital referrals if necessary under the JKN program. The national health insurance program covers some 80 percent of the population or around 222 million Indonesians.

The COVID-19 epidemic, however, has affected virtually every way Puskesmas operate, particularly in regions that are now treating persons under monitoring (ODPs) and patients under surveillance (PDPs).

Medical staff have been split into teams for public education, contact tracing and patient treatment, while some Puskesmas have set aside space in their limited facilities to treat COVID-19 patients in isolation from patients with other respiratory illnesses.

Several Puskesmas doctors told The Jakarta Post they were now prescribing medicines to outpatients based on their reported symptoms without a routine examination to avoid inhaling oral or nasal droplets, through which the coronavirus is transmitted.

A Puskesmas doctor in Sidoarjo, East Java, who requested anonymity, told the Post that it had advised patients not to visit the center unless absolutely necessary. This was not only to prevent transmitting the virus but also because some medical workers had been reassigned to contact tracing and were, therefore, unavailable to see patients.

The Sidoarjo Health Agency’s disease prevention and control head, M. Athoillah, who now heads the regency’s 22-strong contact tracing team, said it was not easy to trace contacts and involving Puskesmas was central to approaching community leaders for better reach.

“The heads of neighborhood and community units have become paranoid,” he said. “When residents return home from Malaysia or Japan, they ask us if they need to report [them] to the police,” said Deborah Johana Rattu, who heads a Puskesmas in Bandung, West Java.

“Our challenge is to for [grassroots] people to be on the same page in how they view COVID-19.”

The social stigma surrounding COVID-19 has led communities to cast out medical workers and cemeteries to refuse to bury the remains of people who have died from the disease.

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